Is It Really a UTI? Do You Know It When You See It?

Is It Really a UTI? Do You Know It When You See It?

Today s Objectives 1. Define Symptomatic UTI versus Asymptomatic Bacteriuria 2. Review RAI MDS Coding Manual Definition of UTI 3. Analyze UTI as a Quality Measure 4. Discuss UTI Assessment, Criteria and Communication with Prescribers 5. Consider UTI Reduction in the Nursing Home from a QAPI Perspective

HQI Nursing Home Improvement Network Health Quality Innovators HQI (formerly VHQC) is your Quality Innovation Network Quality Improvement Organization (QIN-QIO) for MD & VA QIN-QIO s bring Nursing Homes, Hospitals, Communities and Patients together in data-driven initiatives that: Increase resident safety Make communities healthier Better coordinate post-hospital care Improve clinical quality

Why Focus on UTIs in the Nursing Home? UTIs are the most frequently reported infections in long term care 1 UTIs are a significant cause for hospital readmissions and Sepsis 1 Monitoring of symptomatic UTIs helps identify trends in these infections and provide data to improve antibiotic use in your facility: 30-60% of antibiotics in SNFs are for suspected UTIs 2 40-75% of those antibiotics used may be unnecessary or inappropriate 3 1 Agency for Healthcare Research and Quality (AHRQ) Safety Program for Long-Term Care 2 Benoit SR et al. J Am Geriatric Soc 2008; 56: 2039 44 PMID 19016937 3 CDC. The Core Elements of Antibiotic Stewardship in Nursing Homes

Risk Factors Risk Factors for Developing a UTI 1 : Age (especially over 85) Female Neurogenic bladder Reduced Mobility Urinary Incontinence Previous UTI Prostate enlargement Kidney stones Catheters: Foley and condom caths 1 https://www.cdc.gov/longtermcare/staff/index.html

Diagnosing UTIs in the Nursing Home Is it a UTI?

But There s a Change in Mental Status

Remember when A Nursing Home UTI used to be characterized by foul smelling, cloudy urine or a change in mental status

Comparing today s UTI definitions: McGeer Loeb CDC/SHEA (aka Modified McGeer or Stone ) For residents without a urinary catheter: At least 3 of the following signs (a) Fever (~38 o C) or chills, (a) New or increased burning pain on urination, frequency or urgency, (b) New flank or suprapubic pain or tenderness, (d) Change in character of urine, (e) Worsening of mental or functional status (may be new or increased incontinence). McGeer et al. AJIC 1991; 19: 1-6, Loeb et al. ICHE 2001; 22:120-124, Stone et al. ICHE. 2012; 33: 965-977

Important Definitions 1 Bacteriuria: Bacteria in the urine Urinary pathogen 100,000 colony-forming units (CFU) Asymptomatic Bacteriuria (ASB): Bacteriuria in the absence of genitourinary signs or symptoms Symptomatic UTI: Bacteriuria in the presence of genitourinary symptoms Symptoms may include fever, dysuria, suprapubic pain or tenderness, frequency, or urgency 1 Infect Disease Clinics North Am. 2014 Mar; 28(1): 75 89.

When should a U/A C&S be sent? Urine testing should be performed when a resident has localized urinary tract signs and/or symptoms Odorous or cloudy urine are NOT indications for urine culture or analysis. These changes alone do not represent a UTI. Hooten et al. IDSA Guidelines, Clinical Infectious Diseases 2010; 50:625 663 Funded by the Agency for Healthcare Research and Quality (AHRQ) Midthun et al. Journal of Gerontological Nursing 2004 In one study, using urine odor to identify bacteriuria resulted in error in 1/3 of cases Even if urine odor is caused by bacteriuria, this does not indicate that infection needs to be treated unless other symptoms are present.

Why Not Treat It Just in Case? Multiple randomized clinical trials treating Asymptomatic Bacteriuria in LTC residents have shown NO benefit No difference in the # of symptomatic UTIs No improvement in chronic urinary incontinence No improvement in survival Asymptomatic Bacteriuria Treatment is known to cause: Increased Adverse Drug events Clostridium difficile (C. diff ) infection Increased antibiotic-resistant organisms IDSA Guidelines for the Diagnosis & Treatment of Asymptomatic Bacteriuria in Adults. Journal of Clinical Infectious Disease 2005; 4-:643-54 Asymptomatic bacteriuria in adults: AAFP 2006; 74:985-90.

When calling the Prescriber SBAR Tools for UTI Situation Background Assessment Recommendation Go to www.ahrq.gov Search for Suspected UTI & see excellent tools & resources http://www.ahrq.gov/sites/default/files/wysiwyg/professionals/qu ality-patient-safety/patient-safety-resources/resources/nhaspguide/module1/toolkit1/utisbar-form.pdf

Which Criteria do you Follow? Meet with your Medical Director to determine Criteria/UTI definition that works best for your prescribers and your team. AHRQ s toolkit for Suspected UTIs is easy to use (ahrq.gov) INTERACT has a UTI CARE PATH available for download: https://interact2.net/tools_v4.html

UTIs as a Quality Measure CMS UTI Quality Measure Description : The percentage of long-stay residents who have a urinary tract infection Definition of Long-Stay: Cumulative days in facility is 101 days A resident must be in your building for at least 101 days to be included in this measure 15

If they have a UTI, Not so fast I count them on the MDS The MDS 3.0 RAI Manual has very specific coding instructions and conditions that must be met to be considered a Urinary Tract Infection: 1. Diagnosis of UTI in the last 30 days 2. Sign or symptom attributed to UTI 3. Significant laboratory findings 4. Current medication or treatment for UTI in the last 30 days 16

Counting Residents with UTI in past 30 Days 17 Tip Sheet available from HQI

List Action Items, then apply select interventions on a smaller scale Education After Conducting a PIP, Develop an Action Plan Educate all staff on their responsibility to prevent UTI Re-educate staff on UTI assessment & SBAR communication Educate environmental services staff on proper cleaning techniques Conduct competency testing for nurses and CNA s on proper urinary catheter care and perineal care Conduct competency testing for nurses and CNA s on proper hand-washing techniques Provide/send MDS nurse to an MDS training course Provide education to residents, family members, and/or significant others about ways to prevent UTI Access resources, tip sheets and tools from HQI HSAG QIO for California Infection Control Quality Assurance & Performance Improvement Case Study 18

HQI Quality Improvement Focus Nursing Home Improvement Network Team from HQI Sheila McLean MBA, LNHA, CPHQ Vice President Theresa Mandela RN, BSN Improvement Consultant Lisa Mark RN, BSN Improvement Consultant Allison Spangler RN, BSN Improvement Consultant

Contact Us! Theresa Mandela Improvement Consultant tmandela@hqi.solutions Lisa Mark Improvement Consultant lmark@hqi.solutions Allison Spangler Improvement Consultant aspangler@hqi.solutions 20 This material was prepared by Health Quality Innovators (HQI), the Medicare Quality Innovation Network- Quality Improvement Organization for Maryland and Virginia, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. HQI 11SOW 20170112-200800